Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA.
Texas Children's Hospital, Houston, Texas, USA.
J Pain Symptom Manage. 2021 Sep;62(3):e218-e224. doi: 10.1016/j.jpainsymman.2021.04.006. Epub 2021 Apr 20.
It is important to document the domains surrounding end-of-life (EOL) care in the electronic health record (EHR). No pediatric navigator exists for these purposes.
Medical charts were reviewed for documentation surrounding code status and care at the time of death from January 2017 to June 2019.
Creation of a navigator in the EHR to consolidate advance care planning documents, code status orders and notes and EOL flowsheets.
After implementing the navigator, 96% code status changes had supporting documentation, an increase of 35%. The percentage of deaths supported by a psychosocial team (social worker, chaplain and certified child life specialist) increased by 25%. Post-mortem documentation became electronic. Patient level metrics began to be electronically collected.
CONCLUSIONS/LESSONS LEARNED: Little has been published regarding use of the EHR to consolidate EOL documentation in pediatrics. Development of a systematic approach to documentation is critical to providing EOL care and standardizing care delivered.
在电子健康记录（EHR）中记录临终关怀（EOL）相关领域非常重要。目前尚没有针对这些目的的儿科导航员。
回顾了 2017 年 1 月至 2019 年 6 月期间，病历中关于代码状态和死亡时护理的记录。
在 EHR 中创建导航员，以整合预先护理计划文件、代码状态订单和注释以及 EOL 流程图。
实施导航员后，35%的代码状态变化得到了 96%的支持性文件，增加了 35%。得到社会工作人员、牧师和认证儿童生活专家等心理社会团队支持的死亡人数增加了 25%。尸检文件实现了电子化。患者水平的指标开始通过电子方式收集。
结论/经验教训：在儿科中，使用 EHR 整合 EOL 文档的应用鲜少被发表。制定系统的文档记录方法对于提供 EOL 护理和标准化护理至关重要。
